Chapter 8: Dissociation and Somatic Complaints

Raskin examines dissociation and somatic complaints—two categories of mental distress that blur the boundaries between mind and body. The chapter begins with vivid case examples: Lauren, who experiences identity alteration and amnesia; Paul, with unexplained thyroid and digestive problems; Tiiu, a military pilot grounded by numbness in her hands; and Isabel, a businesswoman struggling with hypertension from stress. The posttraumatic model frames these problems as rooted in trauma, explaining how dissociation reflects psychological disconnection (depersonalization, derealization, amnesia, identity confusion, and DID), while somatic complaints manifest emotional distress through physical symptoms such as pain or fatigue. DSM-5-TR and ICD-11 categories are explored in depth, including dissociative amnesia, depersonalization/derealization disorder, dissociative identity disorder (DID), somatic symptom disorder, bodily distress disorder, conversion disorder (functional neurological symptom disorder), illness anxiety disorder (hypochondriasis), psychological factors affecting medical conditions, and factitious disorder (Munchausen’s syndrome). Controversies are highlighted: whether DID is iatrogenic or real, whether somatic symptom disorder is too broad, and whether dissociation can be scientifically validated. Alternative diagnostic frameworks include the PDM-2, which reframes DID as dissociative personality disorder; HiTOP, which situates dissociation under the “Thought Disorder” spectrum; and PTMF, which interprets dissociation as an understandable reaction to oppression and threat. Historical perspectives trace hysteria, the wandering womb theory, Briquet’s syndrome, Charcot’s hypnosis, and Janet’s concept of “double consciousness.” Biological perspectives review neurotransmitters like glutamate, treatments with SSRIs, opioid antagonists, and anticonvulsants, brain structures such as the hippocampus, amygdala, and HPA axis, and psychoneuroimmunology research on stress and immune function. Genetics research shows mixed findings, pointing to both heritability and environmental influence, with 5-HTT gene variations implicated. Evolutionary perspectives suggest dissociation prevents emotional overload and somatic symptoms elicit empathy. Psychological perspectives cover psychodynamic explanations of primary and secondary gain, self-hypnosis in DID, CBT models of conditioning, encoding failure, state-dependent learning, and hyperassociativity, as well as humanistic views of dissociation as meaningful and body-oriented therapies addressing alexithymia and character armor. Sociocultural perspectives highlight culture-bound expressions (spirit possession, Chinese somatization), double dissociation in marginalized groups, and debates over the sociocognitive vs posttraumatic models of DID. Service user narratives reveal stigma tied to abuse, somatic diagnoses, and false memory debates. Systems perspectives discuss family predictors of somatic symptoms, Minuchin’s psychosomatic families, and Internal Family Systems (IFS) therapy for dissociation. The chapter concludes that dissociation and somatic complaints remain elusive yet fascinating, challenging us to see how trauma, stress, culture, biology, and family shape how psychological pain is embodied and fragmented.